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PEDIATRIC ANESTHESIA

Early and Late Reversal of Rocuronium and Vecuronium with Neostigmine in Adults and Children

Joan C. Bevan, MD, FRCA^*, Linda Collins, MB, FFARCSI, Carolyn Fowler, MB, FRCSA, Raymond Kahwaji, MD, FRCPC^*, Harold D. Rosen, MD, FRCPC^*, Michael F. Smith, MD, FRCPC^*, Louis deV Scheepers, MD, FRCPC^*, Catherine A. Stephenson, MB, FRCA, FRCPC^*, and David R. Bevan, MB, FRCA

Departments of Anaesthesia, *British Columbia’s Children’s Hospital and Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada

Address correspondence and reprint requests to Joan C. Bevan, MD, FRCA, Department of Anaesthesia, B.C. Children’s Hospital, 4480 Oak St., Vancouver, BC, V6H 3V4 Canada. Address e-mail to bevan{at}interchange.ubc.ca

We investigated the influence of the timing of neostigmine administration on recovery from rocuronium or vecuronium neuromuscular blockade. Eighty adults and 80 children were randomized to receive 0.45 mg/kg rocuronium or 0.075 mg/kg vecuronium during propofol/fentanyl/N₂O anesthesia. Neuromuscular blockade was monitored by train-of-four (TOF) stimulation and adductor pollicis electromyography. Further randomization was made to control (no neostigmine) or reversal with 0.07 mg/kg neostigmine/0.01 mg/kg glycopyrrolate given 5 min after relaxant, or first twitch (T₁) recovery of 1%, 10%, or 25%. Another eight adults and eight children received 1.5 mg/kg succinylcholine. At each age, spontaneous recovery of T₁ and TOF was similar after rocuronium and vecuronium administration but was more rapid in children (P < 0.05). Spontaneous recovery to TOF_0.7 after rocuronium and vecuronium administration in adults was 45.7 ± 11.5 min and 52.5 ± 15.6 min; in children, it was 28.8 ± 7.8 min and 34.6 ± 9.0 min. Neostigmine accelerated recovery in all reversal groups (P < 0.05) by approximately 40%, but the times from relaxant administration to TOF_0.7 were similar and independent of the timing of neostigmine administration. Recovery to T₁ 90% after succinylcholine was similar in adults (9.4 ± 5.0 min) and children (8.4 ± 1.1 min) and was shorter than recovery to TOF_0.7 in any reversal group after rocuronium or vecuronium administration. Recovery from rocuronium and vecuronium blockade after neostigmine administration was more rapid in children than in adults. Return of neuromuscular function after reversal was not influenced by the timing of neostigmine administration. These results suggest that reversal of intense rocuronium or vecuronium neuromuscular blockade need not be delayed until return of appreciable neuromuscular function has been demonstrated.

Implications: These results suggest that reversal of intense rocuronium or vecuronium neuromuscular blockade need not be delayed until return of appreciable neuromuscular function has been demonstrated. Although spontaneous and neostigmine-assisted recovery is more rapid in children than in adults, in neither is return of function as rapid as after succinylcholine administration.

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